The research goals of this proposal are to improve risk stratification for clinical outcomes of two prevalent and costly digestive diseases: upper gastrointestinal (GI) hemorrhage and colorectal neoplasia, and to incorporate the process for stratification into clinical practice. Project I is a 3-phase study to improve the efficiency of hospital-based care for acute upper GI hemorrhage by testing, implementing, and evaluating the application of clinical decision aids (CDAs) to clinical practice. The specific aim of Phase I is to determine which CDAs are best suited to patients presenting with acute upper GI hemorrhage. Six published CDAs will be tested head-to-head for external validation, clinical applicability, and potential cost savings in two cohorts, each with separate funding: a 3- hospital VA cohort and a 3-hospital non-VA, university-affiliated cohort. Phase II is a reminded-based intervention study, where a CDA-based clinical guideline will be created which define the need for hospital admission, initial level of care, and length of stay (LOS), and will determine the safety, acceptability, and impact of the guideline on complication rates, LOS, and patient satisfaction. Phase III is a durability study to determine the effect of withdrawal of the Phase II intervention of the process of care and the need for a more permanent mechanism to ensure guideline adherence. Project II is based on an ongoing cohort study of adults undergoing screening colonoscopy. The goals are to better understand and estimate risk for colorectal neoplasia based on clinical and endoscopic data, and to make endoscopic screening recommendations more patient-specific. The specific aims are to determine: 1) the risk of advanced proximal neoplasia of the colon based on distal colorectal findings; 2) whether neoplastic polyps, and prior colorectal test results. The long-term plan is to acquire sustained funding from the NCI to follow the screened cohort over time to determine whether integration of the baseline information predicts long-term risk of new or recurrent neoplasia. The information will estimate more precisely individual long-term risk of new or recurrent. My mentoring goals are to: 1) provide methodological support to trainees and faculty; 2) develop a series of didactic lectures and workshops illustrating the principles of clinical epidemiology and patient-oriented outcomes research using specific examples from the literature on digestive diseases. I will devote particular attention to advancing my expertise in the areas of CDAs and quality of life measurement. The K24 award will allow me the time and resources required to prepare grants for long-term funding of both projects and to mentor the next generation of clinical researchers.